Charlotte Noordam: Prevention of Future Deaths Report
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Date of report: 12/08/2025
Ref: 2025-0422
Deceased name: Charlotte Noordam
Coroners name: Ana Samuel
Coroners Area: Birmingham and Solihull
Category: Road (Highways Safety) related deaths
This report is being sent to: Birmingham City Council
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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THIS REPORT IS BEING SENT TO: Birmingham City Council | |
1 | CORONER I am Ana Samuel Assistant Coroner for Birmingham and Solihull |
2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
3 | INVESTIGATION and INQUEST On 18 March 2025 I commenced an investigation into the death of Charlotte NOORDAM. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Road traffic collision |
4 | CIRCUMSTANCES OF THE DEATH On the 8th March 2025 at around 14.12 the deceased was riding a black Yamaha Tracer 700 motorbike registration number [REDACTED] down Frederick Road in Edgbaston towards the junction with St James Road. Upon reaching the junction she failed to comply with the stop sign and crossed into the path of and into collision with an MG 3 motor vehicle registration number [REDACTED], which was travelling with right of way along St James Road. Death was certified at 14.48 at the junction of Frederick road and St James Road. Following a post mortem the medical cause of death was determined to be: 1a Multiple Injuries 1b Road Traffic Collision 1c 1d II |
5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The junction is a crossroads in Edgbaston between Frederick Road (running North South) and St James Road (running East West). Both roads are two way priority. Traffic flow priority is along St James Road. Access northwards to St James row from Frederick Road is controlled by a GIVE WAY. Access southwards to St James row from Frederick Road is controlled by a STOP. Both roads are the subject of a 20mph speed limit Traffic Regulation Order. 2. Birmingham City Council stated that if a new junction being designed from new (i.e. it was not a pre-existing historic arrangement), they would oppose the use of a non-signalised crossroad junction because of the inherent confusion around priority of movement at the crossroad. However, this is a historic highway arrangement. 3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction. 4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25. 5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction. 6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable. 7. I am concerned that there is still a risk to life for users of the junction. |
6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 October 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • The family of Mrs Noordam • West Midlands Police • The driver of [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
9 | 12 August 2025 Signature: Ana Samuel Assistant Coroner for Birmingham and Solihull |